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#26-005485-0008
Supplemental Questionnaire

Last Name
First Name

 

Qualified candidates must meet one of the following criteria.

(A) Hold an earned doctoral degree in a chemical, biological, clinical or medical laboratory science or medical technology from an accredited institution; or
 
(B) Hold an earned doctoral degree; and 
  • (1) Have at least 16 semester hours of doctoral level coursework in biology, chemistry, medical technology (MT), clinical laboratory science (CLS), or medical laboratory science (MLS); or
  • (2) An approved thesis or research project in biology/chemistry/MT/CLS/MLS related to laboratory testing for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings; and
(ii) Be certified and continue to be certified by a board approved by HHS; and
 
(iii) Have at least 2 years of:
  • (A) Laboratory training or experience, or both: and
  • (B) Laboratory experience directing or supervising high complexity testing; and
(iv) Have at least 20 CE credit hours in laboratory practice that cover the director responsibilities defined in §493.1445
 
Note: Candidates must provide proof of Board Certification at the time of application.

1

Do you possess an earned doctoral degree in chemical, biological, clinical or medical laboratory science or medical technology from an accredited college or university?

Yes No
2

Do you hold an earned doctoral degree with at least 16 semester hours of doctoral level coursework in biology, chemistry, medical technology (MT), clinical laboratory science (CLS) or medical laboratory science (MLS)?

Yes No
3

Do you hold an earned doctoral degree and have an approved thesis or research project in biology/chemistry/MT/CLS/MLS related to laboratory testing for the diagnosis, prevention or treatment of any disease or impairment of, of the assessment of the health of, human beings?

Yes No
4

Are you certified, and will you continue to be certified, by a board approved by HHS?

Yes No
5

Do you have at least two years of the following?

1. Laboratory training or experience or both; and,

2. Laboratory experience directing or supervising high complexity testing

Yes No
6

Do you have at least 20 CE credit hours in laboratory practice that over the director responsibilities defined in §493.1445?

Yes No

 

REMINDERS:

  • UPLOAD ALL PERTINENT DOCUMENTATION TO THE APPLICATION BEFORE SUBMISSION (i.e. Licenses, Certifications, Transcripts)
  • CLEARLY INDICATE LICENSE/CERTIFICATION NUMBERS AND EXPIRATION DATES ON THE APPLICATION


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